Staten Island Care Center

Based on observations, record review, and staff interviews conducted during the Recertification survey from 03/14/2024-03/21/2024, the facility did not ensure that the survey results were posted in a place readily accessible to residents, visitors, or other individuals, where individuals wishing to examine survey results do not have to ask to see them. Specifically, the survey results were in a binder at sitting height at the front desk facing towards the inside area of the security desk and were not readily accessible for review. The finding is: The facility policy and procedure titled Survey Results reviewed on 01/08/2024 documented that it is the policy of the facility to post all survey results at the front desk for all residents and visitors to view. Signs are posted throughout the facility indicating where the results can be found. On 03/14/2024 between 09:20 AM and 11:37AM, the facility lobby and all 5 units were observed. In the lobby there was a sign posted opposite the administrative office stating, Please be advised the New York State Department of Health survey results…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews during the Recertification survey from 3/14/24 to 3/21/24, the facility did not ensure that a complete preadmission screening for individuals with a mental disorder was conducted. Specifically, the SCREEN DOH 695 form was incomplete and a determination of a resident's need for Level II services had not been documented. This was evident for 1 of 2 residents (Resident #244) reviewed for Preadmission Screening and Resident Review (PASARR) out of 38 sampled residents. The finding is: Resident #244 was admitted to the facility on [DATE] with diagnoses that included Non-Alzheimer's Dementia, Anxiety Disorder, Depression, Bipolar Disorder. The Annual Minimum Data Set, dated [DATE] documented resident was cognitively intact and that Antipsychotics were received on a routine basis only. The admission Minimum Data Set, dated [DATE] documented that Resident #244 had not been evaluated by Level II Preadmission Screening and Resident Review (PASRR). The Comprehensive Care Plan (CCP) for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews conducted during the Recertification survey from 3/14/2024 to 3/21/2024, the facility did not ensure an ongoing activities program was provided to meet the interests of and support the physical, mental, and psychosocial well-being of the resident. This was evident for 1 of 1 resident (Resident #53) reviewed for Activities out of 38 total sampled residents. Specifically, Resident #53, a resident with severely impaired cognition, was observed for extended periods of time without meaningful activities, and there was no activity plan to provide activities to the resident while in their room. The findings are: The facility policy and procedure reviewed 1/25/24 titled Activities On Unit Programming and House Wide Activities documented an individual program is designed for each unit, composed of leisure education, social recreation, and therapeutic interventions reflecting the interests and needs of the unit's population. This includes the Subacute Unit and Dementia…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews conducted during the Recertification/complaints survey from 3/14/24 to 3/21/24, the facility did not ensure that a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, a resident was not provided with handrolls and a splint device as ordered by the physician. This was evident for 1 of 1 resident (Resident #218) reviewed for Position/Mobility out of 38 sampled residents. The findings are: The facility's Policy and Procedure titled Adaptive devices dated 03/30/2014, last updated 01/15/2024, documented that Licensed Nurse/Certified Nursing Assistant ensures that device is in place in accordance with plan of care and notifies nurse manager/nurse if resident refuses to use the device. Resident #218 was admitted to the facility with diagnoses that included Peripheral Vascular Disease, Other Fracture, Cerebrovascular Accident, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, records review and staff interview during the recertification survey, the facility did not ensure that each resident's right to privacy and confidentiality of his or her personal and medical records was maintained. Specifically, the licensed nurse left an open laptop logged into a resident's electronic medical record (EMR) (Resident #141) and medication blister pack (Resident #83 and Resident #140) unattended, on top of the medication cart, in the hallway, exposing personal health information. This was evident for 3 of 4 residents reviewed for privacy (Resident #141, #140 and #83) on 1 of 5 units (Unit 2). The findings are: The policy and procedure for Health Information Privacy and Accountability ACT (HIPAA) dated 10/1/16 and revised date 12/1/21 documented that it is the policy of the facility to protect the privacy of our residents in the person and as related to their personal health information. To maintain compliance with HIPPA law enacted in 4/13/03 to protect privacy of health care information and privacy of the resident. Information can be gathered at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and staff interviews during the Recertification survey, the facility did not ensure that infection prevention control practices were followed to help prevent the spread, development, and transmission of communicable diseases and infections. Specifically, The facility staff did not follow infection control guidelines while handling clean and soiled linen to prevent the spread of infection; This was evident for 1 of 5 units observed for infection control (unit 5 and unit 1). The findings are: 1) The Infection Control: Safe handling of linen policy dated 6/12/18 last reviewed on 11/9/21 documented that it is the policy of the facility to ensure that all personnel must handle, store, process, and transport linens so as to prevent the spread of infection. Proper handling of linen is required throughout the facility. Nursing staff may take the linen and place on portable linen carts on the unit and must remain covered. At no time should the cover remain open. Care must be taken…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review conducted during a recertification survey (U53P11) and facility reported incident (FRI) complaint investigation (NY00251863) completed on 2/04/2022, the facility did not ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation is made to the State Survey Agency. Specifically, the facility did not report an incident where a resident was noted with a bleeding nose after they were found in another resident's room and this incident occurred on 01/30/2020 at 3:16 PM and was reported to NYSDOH on 01/31/2020 at 04:46 PM. Additionally, a resident was injured by the actions of another resident that occurred on 3/30/2021 at 04:00AM and reported to NYSDOH until 3/30/3021 at 06:37PM. This was evident for 3 of 6 residents reviewed for Abuse (Resident #19, Resident # 415 and Resident # 416). The finding is: The facility policy and procedure titled Abuse, Mistreatment, Neglect, Exploitation and Misappropriation of Resident's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based upon observation, interview and record review during the recertification survey, the facility did not dispose of garbage and refuse properly. Specifically, a garbage container were observed being transported without a cover. The findings are: Policy & Procedure titled Garbage Disposal last review date 11/17/21, documents, It is the policy of [NAME] Island Care Center to ensure that all garbage is handled in a manner which maintains the cleanliness of the facility, maintain infection control and maintain dignity and privacy of items disposed. General Information: All garbage is transported from the location obtained directly to the trash compactor in a covered bin. On 02/01/22 at 11:13AM a Dietary Aide was observed bringing a large garbage container off the elevator to take outside to the dumpster and back down to the kitchen empty. The garbage container was not covered traveling in either direction. On 2/1/22 at 11:17AM the Dietary Aide was interviewed and stated, I am trained to put a cover on the garbage…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility did not ensure that the Minimum Data Set (MDS) accurately reflected the status of the resident. Specifically, Resident #212 had three (3) consecutive MDS document a diagnosis of Schizophrenia. However, there was no corroborating documentation in the resident's medical record supporting this diagnosis. This was evident for 1 out of 35 sampled residents. The finding is: Resident #212 was admitted to the facility on [DATE] with diagnoses which included Post Traumatic Stress Disorder, generalized Anxiety, Depression and Peripheral Vascular Disease. The medical record was reviewed and the following was documented: The Preadmission Screening and Resident Review (PASSR) dated 4/12/18. was reviewed and documented: No dementia diagnosis, no serious mental illness and no Level II referrals were indicated. The Quarterly MDS dated [DATE] in Section I, Active diagnoses: Psychiatric/Mood disorder the diagnosis: Schizophrenia was documented. The Annual MDS dated [DATE] in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews during the re-certification survey, the facility did not ensure infection control practices were maintained to help prevent the development and transmission of communicable diseases and infections. Specifically, a housekeeper was observed exiting the room of Resident #115 who is on contact precautions for Acinetobacter Baumani without wearing personal protective equipment (PPE). He was mopping the floor. The same housekeeper was also observed using the same mop to clean the room of Resident #149. This deficient practice was observed for one housekeeping employee. The finding is. The facility policy and procedure titled, Isolation Procedure (Dated 05/29/18) was reviewed and documented the following. The steps that must be followed by the housekeeper include, check type of isolation, prepare to enter the room by putting on gown, disposable mask, and latex gloves. When preparing to leave room, place wet mop in red plastic trash bags. As defined in the federal…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.